now what I want to talk about in this video will apply to any clinical situation you might find yourself in well indeed any first-aid situation you might find yourself in and it's about how we give priority to various aspects of care prioritization of care and the principles we use here are a B C D and E just the first five letters of the alphabet now why it so happens that these immensely useful clinical principles just fit into the first five letters of the alphabet I've no idea but that they do let's start off with thinking about the first one which is airway absolutely vital that the airway is patent the airway has to be open so the air can go in and out and very often we just assess this by talking to our patient if the patient can talk to us then by definition that means the airway is clear because the vocal cords are in the airway so the vocal cords are vibrating generating the patient's speech then air is going through them and the patient has a patent airway then we can move on but other times were not so sure and in this situation we need to look listen and feel so we look for the patient of the movement the movement of the patient's chest we look for the movement of the patient's abdomen to see if we've got normal ventilatory movements and if we're not sure we can go closer than what I normally do first is put my hand over the patient's mouth and nose and it's very reassuring if you feel the patient exhaling on your hand but if we're not sure we can go closer we can put our ear on or near the patient's nose and we can look down over the line of the patient's chest and abdomen and we can look for movements from that angle and at the same time if there's any breath we can feel it on our ear because the ear is very sensitive and we can also hear it if there's anything if the airs going into that we can hear that with aria so we need to assess this look listen and feel because if the airway is blocked the oxygen is not getting into the patient's body they'll become severely hypoxic and of the OS fully blocked now become unconscious within a few minutes shortly after that they'll get brain damage and damage to the heart particularly the harm us or the myocardium and shortly after that they're going to die I mean it said that oxygen lack first stops the machinery then wrecks the machine so first it will stop the brain from working but then it will go on and you've ever provoked ibly damage the brain permanent brain damage will occur we call it hypoxic brain injury so vital that we keep the airway open and in emergency situations of the patients hypoxic then that's going to cause hypoxia of the myocardium and that's going to make the myocardium more irritable and it won't respond to our resuscitation attempts it's sometimes said that blue hearts don't start which brings us on to another interesting point cyanosis hypoxia will cause a cyanosis through hypoxemia will cause cyanosis so hypoxemia is the lack of oxygen in the blood and that's going to mean the blood becomes darker red but the strange thing is when this dark red blood is seen through human skin and human mucous membranes it gives a blue tint so cyanosis indicates low levels of oxygen as well another important clinical observation now if the patient's airway is not open we need to open it especially with the reduced level of consciousness now what is the most common thing that blocks the airway in an unconscious patient what is the most common cause of airway obstruction well the most common cause of airway obstruction is the patient's own tongue it falls back so what we need to do is extend the neck and that pulls the tongue forward and that opens the airway and normally that will open the airway we reassess we look listen and feel and hopefully we will then see the chest movements feel the air on our hand or ear and hear the patient breathing that will restore it by opening the airway now the exception to this is a patient with trauma of the upper chest neck or head if they're unconscious and can't talk to us then we have to assume they have a cervical spine injury and if we move the neck to extend it we can move the broken vertebrae and that can transect the spinal cord and that can turn a serious injury into a catastrophic injury this is just unthinkable we never want this to happen so in that case where we do is the jaw thrust maneuver and here the fingers go behind the angle in the patient's jaw and you pull the jaw forward commotions bottom teeth sticking over the patient's top teeth and that also pulls the pulls of the air tube forward out of the way of the oropharynx we can open the airway and at this stage in the hospital situation we would certainly give high concentrations of oxygen as soon as that was available now people do worry about oxygen sometimes but giving healthy people high concentrations of oxygen for short periods of time is absolutely safe now I know some people are what we call carbon dioxide retainers and that they often can stop breathing if we give them too much oxygen but it's important to remember these patients will still die through a lack of oxygen the same as anyone else so in emergency situations we tend to just put high levels of oxygen on not everyone so that's a four airway moving on now to be for breathing and of course this is this is just an integral part of every clinical assessment isn't it we assess the rate of breathing so we know the patient's respiratory rate if it's too high that's tacky paneer if it's too low that's brandy paneer we want we want the rate to me between we say 12 and 20 we accept as normal we'd also examine the assess the rhythm of breathing is a regular rhythm to the breathing and at this stage we can also take the patient's oxygen saturations on a finger or Honoria if the periphery shut down use it use a central point is often better and we would assess their oxygen saturations and we certainly want those to be above 94% and we're also listening at this stage so partial obstruction for them for example of the upper airway we'll call what we call stride or where we can hear the air going past an obstruction of course if this complete blockage of the airway there's going to be no sounds at all but we can hear this stride or sometimes obstruction of the upper airway or if there is Blanco constriction in the lower Airways that usually gives rise to a wheezy sound so we can listen to that and it gives us a lot of clinical information we can also pick us the chest we could listen with it with a stethoscope and another quick test especially in trauma is just make sure that the trachea is central because of the kids deviated that can indicate pressure so for example if a patient had a tension pneumothorax after an injury on the right side of the chest that will push the trachea across to the left the tracheal deviation very quick and easy to test for now in some clinical situations we can improve the patient's breathing just by sitting them up patients breathe better when they're sitting up in other more emergency type situations if the patient's not breathing then we need to breathe for them now normally the diaphragm goes down the ribs and intercostal muscles goes up in and out that increases the volume of the chest that reduces the pressure and air is sucked in we are negative pressure ventilator and if a patient can't do that for themselves for some reason then we can breathe for them by blowing air in this is called positive pressure ventilation intermittent positive pressure ventilation and here in a hospital situation we'd use a bag valve mask and we'll probably use airway adjuncts an airway adjunct is just anything they use to help you with the airway so we might use an oropharyngeal airway or a nasal airway or an eye gel or possibly even endotracheal intubation in first-aid situations you might just need to use mouth-to-mouth ventilation but the principle is the same we are using external pressure to blow air into the patient's lungs so we have breathing now if you say to a patient are your a and B satisfactory and they say I don't know what you're talking about then by definition that means that they're a and B are okay because the as we've said the vocal cords are in the airway and they're breathing too facilitator to facilitate speech so going on to C C stands for circulation and again this is just intrinsic to all of our clinical observations and assessments so what is the patient's heart rate what is their pulse doing and learn to palpate peripheral pulses and also learn to palpate central pulses because if the patient is in an emergency situation is in there and their blood pressure is low and the peripheral pulses will go so remember when the blood pressure is low the peripheral pulses go so learn to palpate the carotid and the femoral pulses as well use your machines by all means but there's no substitute for for palpating the pulse and of course do the patient's blood pressure and test their to pillory refill time as part of the assessment of circulation so we press the fingernail beds for five seconds and we want them to go pink again in under two seconds but sometimes if the patient's peripherally shut down we can do what we call a central there the central capillary refill time and do it on there I normally press over the sternum and watch the capillaries repr fuse after five seconds of pressure heart rate blood pressure we can also assess the the heart rhythm if we've got video that relevant equipment with us at this stage now D stands for disability now the nervous systems not working that's going to cause disability so D for disability is really about our assessment of the nervous system and of course there's many ways we can do this but to start off with we can use these principles of gap the gap principles to assess D for disability for nervous system now G is for glucose because of the patient's hypoglycemic they'll be unconscious make no mistake hypoglycemia causes unconsciousness and will cause death if we don't recognize it so at this stage we check for glucose and AB Pugh is is the patient alert are they responsive to voice are they responsive to pain or are they unresponsive that's the of proof score and that gives us a very rough indication of the patient's loc their level of consciousness if more time was available of course we can do a full Glasgow Coma Scale assessment looking for a normal level of consciousness of 15 another quick and easy test is the pupils to shine a light in the pupils and both equal should constrict blissfully when we shine a light in them in they should be completely equal if they're not then could well be something going on it inside the inside the cranial cavity for example if there's a bleed in the right side of the cranial cavity that can cause a dilated and sluggish right pupil but do be careful because a minority of people do have unequal pupils anyway for other reasons and also at this stage we could test for lateral izing signs so do the hands have equal power do the arms have equal power are the legs moving equally to make sure that the the motor function on both sides of the body is equal because if it's not that's what we call lateral izing signs so for example if there is an intracranial bleed on the right side that could cause weakness in the left arm and the left leg so that's d for disability exposure so now we certainly don't want to expose our patients all the time but in in a trauma situation especially we need to inspect all of the patients of the surface or the surface of the patients body so do maintain their dignity do get chaperoned if you feel that's appropriate but the patient's whole body needs to be needs to be examined in exposure not made up a couple of other things for you as well environment so we need to maintain a private environment certainly when the patient is being exposed the patient dignity must be maintained at all times it really is not negotiable and also it's important to think about the temperature for example if a patient has internal bleeding and the environment is cold the patient's body temperature can drop and that will reduce the coagula bility of the blood because blood clots best at 37 degrees centigrade because it's more based on enzymes so when the body temperature is low the blood will flow we have to maintain adequate body temperature adequate environment so think about the environment make it as comfortable and therapeutic as possible and if you want a constant for everything else as well we would go on to what we call the secondary survey so this is at this a b c d e really is what we call the primary survey we can then go on to a much more detailed head-to-toe examination of the patient of that it is appropriate now treat life-threatening problems first before moving on to the next so we assess the airway and we make sure the airway is patent before we go on to b then we make sure the patient's breathing adequately before we go on to see so if interventions are needed to make sure the patient is breathing properly we would do that before we go on to C so these things are assessed untreated as we find them in sequential order it's not like we look for to assess a B C D and E and then go back in 3a no we assess a then we treat a we assess B that we treat B we assess C then we treat see the other things I'm afraid just have to wait and of course we need to assess the effects of the treatment we do this in everyday life don't we try something always say well is that work then so we need to make sure that when we open the airway it is opened that when we are assessing when we're treating the patient's breathing that we are in fact ventilating the lungs effectively we need to assess the effects of our of our treatment if we're assessing it will assess C or we find the patient has no circulation then we need to carry out chest compressions but we need to assess that these are working properly as much as we can so assess the effects of treatment now we never need to keep a clinical clinical situation secret from our from our colleagues especially in emergency situations so as soon as we run happy call for appropriate help early now I've called the help on many occasions and often I've needed that help but other times I've shouted for help and it turns out it wasn't such a big deal after all I didn't really need the help and likewise many times people have said can you help me please and I've ran into a cubicle and it turns out that sometimes they don't need help it was just a bit of a false alarm well that's absolutely fine I'd rather be called 999 times when it was unnecessary then someone missed that one time when they really didn't need help so feel free to take a second opinion feel free to call for help anytime you you are remotely uncertain but certainly in emergency situations call for help at the earliest stage anytime you're remotely uncertain call for help this is a team effort now in trauma the ATL s guidelines are slightly different so well they're the same really but we'll talk about airway with cervical spine control so in trauma rather than just saying airway say airway with c-spine control the to just go together breathing with ventilation the to just go together again and in trauma circulation with hemorrhage control so the hemorrhage control comes under si but there is an exception to this now military people medical people have been uncomfortable for some time with the ABC and this was formalized in the Gulf War in filth first Gulf War in 1991 where these principles were agreed by the British military and all militaries see ABC is the priority so sometimes a C takes priority over a and C stands for catastrophic hemorrhage so if some soldiers might be walking along and one of them steps on a landmine and sustains a higher end this injury and legs blown off just unimaginable levels of violence and trauma but it happens and there the there were healthy seconds before so there are airway breathing is okay the problem is they've got catastrophic blood loss so that would be addressed first public by arterial clumping by torniquet is by direct pressure so in some situations catastrophic hemorrhage is dealt with first then we go on to airway breathing circulation that's the only exception I can think off to the ABCDE priority of care if this catastrophic hemorrhage complete an initial assessment and reassess so this is not a one-off process it's not that we say well I've checked ABCDE am now going for a cup of tea now no no we need to constantly monitor and reassess for example we might assess that the patient's airway is patent in a patient with low levels of consciousness but then the vomit and then the airway is not patent they can obstruct the airway by inhaling vomit and they can get aspiration pneumonia so we need to constantly reassess or a patient might be breathing satisfactorily at one stage then they get a severe allergic reaction bronchoconstriction for example and then of course they're not breathing we need to constantly reassess this is not a one-off process it's an ongoing assessment process so we assess we intervene we reassess an ongoing process and as we reassess we assess the effectiveness of our intervention now of course if you've got a team with you that's that's wonderful if we've got a trauma coming in and in the A&E situation we'll have an airway person a breathing person a circulation person and they've got all got assigned roles and that can all be done simultaneously if we're in a team situation so that's nice because a is still being done with immediately but at the same time people are simultaneously dealing with other problems in a severely traumatized patient the team as wonderful communicate effectively using the situation background assessment recommendations again these were developed by the military I think this was developed by the the American Navy but it works very well so I might go to my consultant and say the situation is mr. Smith in cubicle one has gone into cardiac arrest I think he's got a ventricular fibrillation the background is that he came in with chest pains suspected myocardial infarction I was just doing the 12-lead and they went into ventricular fibrillation so my assessment is we're in a cardiac arrest situation ventricular fibrillation my recommendation is that basic life support is carried on and that man's life support is indicated for though of course the consultant should know that but feel free to recommend it anyway so no it really works at this s bar if you go through that it works and we get clear communication there's been so many catastrophic things have gone wrong in healthcare through its simple lack of communication and this sbar really does help I think it's a great tool so there we are ABCD and E